Surgical Safety and Quality in Hospitals and Ambulatory Surgical Centers

Clearly quality, like beauty, is in the eyes of the beholder.

Humphrey Taylor, Chairman of Harris Poll and Harris Interactive, in The Health Care Blog

On the public's eye , safety has moved from and center since the recent death of 81 year old comedian Joan Rivers in a New York City ambulatory surgical center (ACS) from a seemingly minor biopsy procedure of her vocal cord.

Her unexpected death has raised this question: Are ambulatory surgery centers as safe as hospital surgical suites, where theoretically, resuscitation teams and resuscitation equipment are more available? This has lead to articles like “Quality and Safety in Ambulatory Surgical Centers” (Cheryl Clark, Health Leaders Media, November 18. 2014).

The question may be irrelevant. Hospitals are moving quickly to set up ambulatory surgical centers of their own, often in joint ventures with physicians, outside of hospital walls, in response to public demand, dangers of hospital-borne infections such as Clostridia Difficile, MRSA, and other antibiotic organisms, healthy consumers flocking to ambulatory centers, and hospitals suffering from competition from physician-owned ambulatory surgery centers.

The rapid formation of ACSs is made possible by faster, better anesthesia, less invasive procedures with small incisions, greater efficiencies and lower costs, public awareness that hospitals are dangerous places, and the simple reality that most surgeons prefer to operate in ACSs, when the patient is able, younger, needs a less complicated procedure , requires only a short length of stay, or has limited funds.

There’s another factor as well. Safety is not the same thing as quality.

Safety is freedom from occurrence of risk , injury, and complications.

Quality is a different animal. It resides in the eyes of the beholder- the patient, the physician, the supplier, the insurer, and the government overseer.

• Patients who use ACSs define quality as getting as much care as you get – the more the better, especially when it quicker, simpler, cheaper, more direct, more personal, friendlier, with more bedside matter, more amenities, such as valet parking; more modern facilities . That’s why consumers tend to prefer detached new ACSs over older centralized hospitals.

• Employers who send patients to ACSs look upon these centers as getting more bang for the buck for employees and retirees, as offering quicker, more direct care for common procedures for otherwise healthy workers, without building a corporate team to deal with the complexities of an overly complicated system.

• The Institute of Medicine and other judgmental organizations regard quality as avoidance of medical errors and implementation safety systems, which are invisible but necessary.

• Surgeons who work in ACSs think of quality as good outcomes, happy patients, a hassle-free environment, lack of restrictions and obstacles to care, greater efficiencies with more time for the job to be done and less time devoted to paperwork, your choice of surgical tools and nurses devoted to your cause, and less worry about how you’re to be paid with direct pay for what is done.

• Drug companies equate quality with use of their latest brand name drugs , a high level of compliance, and strict adherence to drug regimens, and access to physicians who use their drugs and influence other physicians.

• Government technocrats, policy makers and wonks, public health advocates believe quality resides in population health measures, wellness with avoidance of smoking and obesity, high immunization rates, longer life expectancy, and wider use of data and evidence-based medicine.

These health care stakeholders are like the Six Blind Men of Indostan, who, after feeling the various parts of the health care elephant, have their own impressions of what constitutes quality. Each is his own way is right, each is partly wrong, and each has a limited view of quality or the system as a whole.